LEPROSY

Dr. MD AKBAR KHAN

MS (ORTHO) ASSISTANT PROFESSOR

A C S R Government medical college,

nellore
Reconstructive Hand & Foot Surgeon
Damien Foundation india trust
Nellore

DEFINITION
Leprosy is a chronic granulomatous disease,
caused by mycobacterium leprae, which affects
principally the skin and peripheral nervous
system

Every year January 27 is World Leprosy Day

2

History of Leprosy
Leprosy has existed since biblical
times
Once existed in Europe from 1
2000 BC, it has since
disappeared in Europe
Leprosy still exists in many
countries in Asia, Latin America,
and Africa
3

Modern History of Leprosy

1873: Doctor Armaur
Hansen of Norway
discovers M. Leprae
bacilli
1950s: Doctors begin
using Dapsone to treat
leprosy
1982: Leprosy develops
resistance to Dapsone;
who recommends multidrug treatment

Epidemiology
Total No of Leprosy cases in the world 1.5 Millions
Endemic areas 83% of Leprosy cases concentrated in
only 5 countries India, Brazil, Nigeria, Myanmar &
Indonesia.
Nearly 75% of worlds Leprosy patients are in South East
Asia.
Highest No of Leprosy In India (Bihar, Uttar Pradesh)

Bacteriology
Morphology : Pleomorphic straight or
slightly curved rod like, gram positive
bacteria
Zeil Neelsen Staining: Bacilli appears as
solid staining (viable), fragmented and
granular (dead bacilli)
Incubation Period : 2 5 years
Life Span 6 months
Cannot grow in artificial media or tissue
culture
Generation Time : 10 14 days

Mode of transmission
The exact rout of transmission is not fully known .

Although human-to-human transmission is

the primary source of infection
The spread of leprosy is believed to be via
nasal discharge (Droplets infection).
Results in skin lesions and deformities, most
often affecting the cooler places on the
body (eyes, nose, earlobes, hands, feet, and
testicles) that can be very disfiguring.
Every 1 cc of nasal secretion contains 1- 2millions lepra bacilli

Other modes of transmissions

1. Contact through the skin (rare).
2. Arthropod-born infection (rare).
3. Through placenta and milk.

The nine - banded armadillo

10

Signs and Symptoms

Early signs and symptoms of leprosy are
very subtle and occur slowly (usually
over years).

First symptoms :

Numbness and loss of temperature

sensation (cannot sense very hot or
cold temperatures)

As the disease progresses :

The sensations of touch, then pain,

and eventually deep pressure are
decreased or lost.
11

Long-term developing sequence of

events :
Relatively painless ulcers,
skin lesions of
hypopigmented macules
(flat, pale areas of skin), and
eye damage (dryness,
reduced blinking)
Late stage: large
ulcerations, loss of digits,
and facial disfigurement.
(for example, hands, feet, face, and
knees).

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redisposing or risk factors

1.
2.
3.
4.

Residence in an endemic area.

Poverty (malnutrition).
Contact with affected armadillo.
Immunity

13

lassification & Clinical Presentation

Ridley &Jopling Classification

Based on Host Immunity

TT

BT

BL

BB

LL

BL
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Classification & Clinical Presentation

WHO Classification
Based on Bacterial Load
Slit Skin Smear

Negative

Positive

Paucibacillary
skin lesions 1-5

Multibacillary
skin lesions 6<
15

LEPROSY

Paucibacillary (PB)

Multibacillary (MB)

Indeterminate Leprosy (IL)

Borderline Borderline (BB)

Tuberculoid Leprosy (TL)

Borderline Lepromatous(BL)

Borderline Tuberculoid (BT)

Lepromatous Leprosy (LL)

16

Indeterminate Leprosy (IL)

Usually single (multiple) macule / patche

Hypopigmented or faintly erythematous.
Sensation normal but sometimes
imparied.
The peripheral nerves normal.
Slit skin smear negative.

Indeterminate leprosy :Hypopigmented patch, sensation normal, no

.palpable peripheral nerve and slit skin smear negative
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Tuberculoid Leprosy (TL)

Usually single but may be few (<5).
Hypopigmented / erythematous plaque.
Varying in size from few mm to several
cm.
Well defined borders.
Sensation markedly imparied.
Enlarged peripheral nerve.
Slit skin smear negative

Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic

.well defined borders, palpable peripheral nerve and SSS negative
20

Tuberculoid Leprosy: Annular, erythematous, anasthetic patch with

.well defined and raised borders and SSS Negative
21

22

Borderline Leprosy
(BT,BB,BL)

Few / many asymmetrical patches.

Partly well-defined borders.
Sensory impairments range from slight
to marked.
Slit skin smear usually positive.
P. nerves asymmetrically enlarged.

BL
BB
Many
Some
Roughly
Less
Slight
Moderate
Roughly
symmetrical Asymmetrical

BT
Few(<5)

. Lesion no

Well

Lesions borders

Marked

Sensory
impairment

Asymmetrical

Less
asymmetrical Asymmetrical

Distribution
of skin
lesions
Asymmetrical Peripheral
nerves

Multibacillary

Multibacillary

Paucibacillary

4+

+3 / + 2

Type of leprosy
Slit skin smear

/ 1+
24

Note: Sometimes patients may have BT/BB or BB/BL or BL/LL

Borderline Tuberculoid Leprosy: Well-defined large anaesthetic patches

.with satellite lesions. SSS Negative
25

Borderline Borderline Leprosy: Less defined, asymmetrically distributed

.hypoaesthetic patches. SSS positive
26

Borderline Lepromatous Leprosy: Numerous, hypoaesthetic almost

.symmetrically distributed patches . SSS positive
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Lepromatous Leprosy (LL)

Very numerous ill defined lesions.
(macules, patches, papules,and
nodules).
Symmetrically distributed allover the
body
Loss of eyebrows and eyelashes.
No sensory impairments in lesions .
Peripheral nerves symmetrically
enlarged.
Slit skin smear always positive.

29

30

Lepromatous Leprosy: Leonin Face

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Diagnosis of Leprosy
1. Clinical Examination.
2. Slit Skin Smear.
3. Skin Biopsy.

32

1.Clinical examination:
What are the cardinal skin signs of leprosy ?
1. Hypopigmented or erythematus patch / plaque
2. Complete / partial loss of sensation.
3. Thickening of peripheral nerves.

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2.Slit Skin Smear

Simple and valuable test.
It is needed for diagnosis.
Monitor the progress of the
treatment.
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Slit Skin Smear (method).

Pinch the site tight.

Incise.
Scrape & collect material
Smear on a slide.
Air dry & fix.
Stain (Z-N method)

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Slit Skin Smear (Reporting the smear).

Ridleys logarithmic(
scale)Bacteriological
index
no bacilli in 100 fields 0
bacilli in 100 fields 1-10: +1
bacilli in 10 fields 1-10: +2
bacilli in 1 field 1-10: +3
bacilli in 1 field 10-100: +4
in 1 field 100-1000: +5

 BI is calculated by adding
up the index from site
examined and dividing by
the total number

Morphological
index
The percentage
of living
bacilli(solid
staning bacilli)
to the total
number of
bacilli in the
.smear

Other
smear
techniques
Nasal smear
Nasal
scrapings

Clinical spectrum of leprosy

Immunity

Skin Lesions

No. of Bacilli

Slit skin test

TT

BT

BB

BL

41

LL

Skin Biopsy

Tuberculoid Leprosy (TT).

Histologically
tuberculosis.

TT

resemble

Characterized by tuberculoid
granuloma, made up of epitheloid
cell in the center surrounded by
abundant Langhans giant cells,
lymphocytes and foci of caseating
necrosis.

Lepromatous Leprosy (LL)

Characterized by diffuse infiltration of
foamy macrophages in the
dermis.
Acid-fast bacill are present inside
these foamy cells eighter singly or in
globi.
There is free subepidermal zone
(grenz zone).
Lymphocytes are scanty and giant

Other tests:
Histamine test: for the
diagnosis of indeterminate
leprosy
Immunological tests
Test for detecting CMI
Test for detecting
antibobies

Test for detecting CMI

Lepromin skin test :
To differentiate the two
different forms of leprosy
apart, but it is not used to
diagnose the disease
Because:false negative and
false positive

Lepromin Skin Test

Procedure to Lepromin Skin Test
A tiny sample of leprosy antigen is
injected under the skin, usually in the
forearm.
The skin gets pushed up, forming a
small bump.
This is an indication that the antigen
has been injected to the correct depth.
The site of the injection is marked, and
is examined for reaction, first after 3
days(early reaction-Fernandez
reaction:-redness and induration)
and then again after 21 days(late
reaction-Mitsuda reaction:-

Test for detecting

antibobies

1.Fluorescent leprosy antibody

absorption test(FLA-ABS
test): Now widely used for
identification of subclinical
cases
92.3% Sensitive & 100%
specific

2.Monoclonal antibodies

TREATMENT

Today, the
diagnosis and
treatment of
leprosy is easy
and most
endemic
countries are
striving to fully
integrate
leprosy
services into
existing
general health

LEPROSY IS A CURABLE
DISEASE
Drugs used in Leprosy treatment

What are the three commonly used drugs?

1. Dapson.
2. Rifampicine.
3. Clofazimine.
The combination of these three drugs is
known as Multi Drug Therapy (MDT)

HISTORY OF TREATMENT

In 1941, promin, a sulfone drug, showed efficacy

but required many painful injections.
Dapsone pills were found to be effective in the
1950s
But soon (1960s-1970s), M. leprae developed
resistance to dapsone.
. In the early 1960s, Rifampicin and clofazimine, the
other two components of MDT, were discovered.
This multi-drug treatment (MDT) was
recommended by the WHO in 1981 and remains,
with minor changes, the therapy of choice.
Since 1995, WHO provides free MDT for all
patients in the world
NB: MDT, however, does not alter the damage
done to an individual by M. leprae before MDT is

 MDT (Chemotherapy) renders Leprosy

patients non-infectious. after three

months of continuous treatment with dapsone

or clofazimine, or after two to three weeks of
treatment with rifampicin.

MDT for PB
leprosy
6 months

54

Monthly dose
Rifampicin
600mg

Daily dose
Dapsone 100
mg

Multidrug Therapy (MDT) for Paucibacillary Leprosy (PB)

55

MDT for MB
leprosy
12 months

56

Monthly dose
Rifampicin
600mg
Clofazimine 300mg

Daily dose
Dapson 100mg
Clofazimine 50 mg

Multidrug Therapy (MDT) for Multibacillary Leprosy (MB)

57

Multi Drug Therapy

6 months

24 months

58

OTHER DRUGS : Ethinamide and

protionamide
Quinolones
Minocycline
Clarithromycin
59

COMPLICATIONS
OF LEPROSY &
ITS
MANAGEMENT

COMPLICATION CAN BE
CATEGORISED AS:
1) LEPRA REACTION
2) ADVERSE EFFECT OF ANTI-LEPROTIC
DRUGS
3) DISABILITIES & DEFORMITIES
4) PSYCHO-SOCIAL PROBLEMS
61

 LEPRA REACTION:
May occur before/during/after MDT.
Not caused by MDT.
Type1 (Reversal reaction)
Type2 (ENL)

Type I

Change in host CMI

Seen in borderlines
Skin and nerve lesions

Type II

Antigen antibody
Seen in LL & BL leprosy
Skin, nerve & systemic
involvement
62

LEPRA REACTION
Treat Reaction as a Medical Emergency:
Rest & Analgesics
DOC-Prednisolone(40-60 mg)
Taper gradually over 12-16 wks.
All need a detailed Neuromuscular
assessment by a physiotherapist.
Erythema Nodosum Leprosum(ENL)
Erythematous.Tender
.Subcutaneous.
Resolve in 7 to 10 days.
Associated with fever & joint pains.
May be vesicular, pustular & may
ulcerate

63

ADVERVE EFFECT OF ANTI-LEPROTIC DRUGS

DRUGS

MINOR

MAJOR

1. RIFAMPICIN

RED URINE

JAUNDICE

GIT UPSET

HEPATITIS

FLU LIKE SYNDROME

SHOCK

GIT UPSET

DAPSONE SYNDROME

DRUG RASH

AGRANULOCYTOSIS

ANAEMIA

HEMOLYTIC ANAEMIA

GIT UPSET

ACUTE PAIN
ABDOMEN

2. DAPSONE

3. CLOFAZIMINE

DISCOLOURATION OF SKIN
ICHTHYOSIS

64

DISABILITIES

Disabilities such as loss of sensation

and deformities of hands/feet/eyes occur
because:
Late diagnosis and late treatment with MDT

Advanced disease (MB leprosy)

Leprosy reactions which involve nerves
Lack of information on how to protect
insensitive parts
Only about 10-15% of leprosy affected
65
person develop significant deformities and

TYPES OF DEFORMITIES:
1) Specific deformities:
- b/c of local
infection with
M.Leprae
- seen most often in
the face; facies
leprosa(loss of
eyebrow,nasal
deformity),
gynecomastia,less
often in the hand

66

2) Paralytic
deformities:
- result from damage
to motor nerve.
-seen most often in the
hand(claw finger),less
often in the feet
&occassionly in the
face(lagopthalomos,fa
cial palsy)

67

3)Anesthetic deformity :
- Occur as a consequence of
neglected injuries in part
rendered insensitive b/c of
damage to sensory nerve.
- Found most often on the feet
and hand(ulceration,scar
contrature,shortening of
digits,&skeletal disorganization
of foot)

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WHO GRADING OF DISABILITIES IN LEPROSY

EYES

HANDS

FEET

WHO Grade
0
Normal
vision,lid
gap,blinking.
Normal
sensation &
m.power.

Normal
sensation &
m.power.

Grade 1

Grade 2

Corneal reflex Reduced

weak
vision,lagoph
thalmos.
Loss of
Visible
feeling in the damage:wou
palm
nds,claw
hand,loss of
tissue etc.
Loss of
Visible
feeling in the damage:wou
sole
nd,foot
drop,loss of
69 tissue.

Peripheral nerves
Sensory
Hypoaestesia / anaestesia

Ulcers

70

Motor
Muscle paralysis

Ulnar nerve
Claw hand
Radial nerve
Wrist drop
Lt. popliteal
Foot drop
Post. tibial
Claw toes
Facial
lagophthalmous

Autonomic
Lack of sweating & sebum

Dry skin
Cracked skin

Ulcers

71

FOOT AND HAND CARE

PRACTICE
Clean with soap & water

Infected ulcer/Cracks

Wounds/injury

Rest & apply antiseptic

dressing
Apply cooking oil/Vaseline
Soak in water
Clean and apply clean
bandage
Protect when
working/cooking
Oil massage
Exercises

weakness/paralysis
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COMPLICATIONS
OF

EYE

Involvment of the ophthalmic division of the (5th.) trigeminal nerve

Corneal sensation imparment

Patients ignore injuries

keratitis, conjunctivitis and ulcers

Unable to close the eye (unbliking stare)

Lagophthalmos

. Involvment of zygomatic & temporal braches of the (7th.) facial nerve

74

75

Care of eyes
Redness and pain

Injury to cornea

Difficulty in closing
eye

Aspirin or
paracetamol
Atropine and steroid
ointment
Cover with eye pad
Apply antibiotic
ointment
Refer
Tear substitute eye
drops
Exercises
76
Dark glasses
to

PSYCHO- SOCIAL
PROBLEMS
-are related to widely held beliefs and
prejudices concerning leprosy & its
causes.
-they often develop self stigma,low self
esteem & depression as a result of
rejection and hostility,
-need to be referred for proper
77
counselling.

Leprosy
control
78

Methods of Control
Medical
methods
Estimation of
problem
Early detection
Multi drug
therapy
Surveillance
Immunoprophylax
is

Social
support
Programme
managemen
Evaluation
79

Rehabilitation
Community based
rehabilitation is
recommended by WHO
Is a strategy within general
community development for
the rehabilitation,
equalization of oppurtunities
and social inclusion of all
people with disabilities.
80

Surveillance
For PB; clinically at least
once a year for 2 years
after treatment
For MB; at least once a
year for 5 years after
treatment

81

Evaluation
i. Epidemological
indicators

Incidences
Prevalence

ii. Main or core indicators

for monitoring progress

No. and rate of new cases

detected per year
Rate of new cases with
grade2 disabitities82per

Evaluation(continued
)
iii.Main indicators for evaluating
case detection

Proportion of new cases presenting

with grade 2 disabilities/impairements
Proportion of child(<15yo) cases
among new cases
Proportion of female cases among new
cases
Proportion of MB cases among new
cases
83

Evaluation(continued)
iv . Main indicators for assessing the
quality of services
Proportion of new cases verified as
correctly diagnosed
Proportion of treatment defaulters
No. of relapses
Proportion of patients who develop
new/additional disabilities during
MDT.
84

WHO Enhanced Global Strategy

2011 2015

Early case detection and treatment

Prevention of disability
Community based rehabilitation
Priority: equality, human rights
Monitor the threat of drug resistance

85

MILESTONES
OF NLEP IN
INDIA
86

Evolution of NLEP

(1955)

National Leprosy
Control Programme

(1980)

Govt. decided to
eradicate leprosy

(1983)

National Leprosy
Eradication Programmme

1997
- Modified Leprosy Elimination Campaign
(MLEC)
2001 to 04 - SAPEL and LEC
200587

Urban Leprosy Control Programme

2009-2010

-DPMR

National Leprosy Control

Programme
Since 1955, centrally aided
To control Leprosy through
Early detection of cases
Dapsone monotherapy

Fourth

Five year plan- centrally

sponsored
1980- Eradicate Leprosy By 2000
Working Group
Revised strategy based on multi- drug
chemotherapy
Aimed at Eradication

88

 Eradication

was planned through

Reduction in the quantum of infection in the

population
Reduction in the sources
Breaking the chain of transmission

National

Leprosy Eradication
Programme- 1983

89

Strategies: OF NLEP:1) Decentralization and institutional development

- services available in all PHCs
- District nucleus to Supervise and monitor
- State leprosy societies merge with state health society
2) Strengthening and integration of service delivery
Diagnosis and treatment- more easily available
Daily outdoor services in PHC
Counseling of patient and Family

90

3) Disability care and prevention

- Reconstructive surgery is promoted
- Rehabilitation institutions
- Supply of MCR footwear
- persons affected by Leprosy to receive
Disability certificate to enable them to get
the facilities available under schemes of
Social welfare department.
4) IEC Campaign
- Country wide press advertisement on Anti
Leprosy Day i.e. 30th January
- The year 2008-09 was observed as a
campaign on the theme Leprosy Free India,
all over the country
5) Training
91

DPMR
The best way to prevent disabilities is:
Secondary prevention i.e.,early diagnosis and
prompt treatment with MDT

Inform patients (specially MB) about common

s/s of reactions
Ask them to come to the centre (as soon as
possible)
Start treatment for reaction
Inform them how to protect insensitive hands/
feet /eyes
Involve family members
92

PARTNERS OF NLEP
WHO, Nippon Foundation,
Novartis, World Bank
ILEP agencies
National Governments &NGOs

93

Modified Leprosy Elimination

Campaign

Mid term appraisal of NLEP in 1997

Though progress was satisfactory at
national level, it was uneven in some
states
MLEC involved
1. Orientation training to health staff
2. Increase public awareness
3. House to House search in endemic districts to
detect new leprosy cases throughout the country
for 6 days

94

SAPEL & LEC

In addition to regular surveillance activities

Rural areas- Special Action Project for
elimination of Leprosy
Urban Areas- Leprosy Elimination
Campaigns
1. For early detection and prompt treatment
2. IEC in rural/ tribal/ slum areas
3. 1440 SAPEL/LEC projects decentralized
during 2001-04

95

Urban Leprosy Control

Programme

Since 2005, Govt. of India funding

Population <1 lakh in 422 urban areas
Graded assistance- urban areas:into 4
categories
1. Township
2. Medium Cities-1
3. Medium Cities-2
4. Mega cities

96

ASHA Involvement

2008-09, ASHAs were involved for

suspecting leprosy cases and after
diagnosis, follow up till treatment
completion.

Incentive for confirmed leprosy cases

out of suspect brought by them (Rs.
100/-) and for completion of
treatment in time (PB- Rs. 200/-, MB
Rs. 400/-).

The scheme was initially put on pilot

basis in 5 major states of Uttar
Pradesh, Bihar, Chhattisgarh, West
Bengal and Jharkhand
97

Anti Leprosy Activities in

India
Leprosy Mission (W.B.)- founded in 1874 in H.P.
Hind Kusht Nivaran Sangh
Gandhiji Memorial Leprosy Foundation,
Sevagram, Wardha
The German Leprosy Relief Association
Damien Foundation
The Danish Save the Child Fund
JALMA- taken over by ICMR in 1975
National Leprosy Organisation- 1965
98

"Leprosy work is not merely

medical relief; it is
transforming frustration of
life into joy of dedication,
personal ambition into
selfless service"
Mahatma
Gandhi

Conclusion
Fortunately, modern medicine has cured most
of the world of Leprosy
People with Leprosy are being more accepted
by communities around the world
Leprosy still Remains a problem in
undeveloped countries
The World Health Organization is putting a stop to
this
If they reach their goal, Leprosy should be
eliminated from the world within 20 years

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Join Hands for a better tomorrow...

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